General Surgery Coding Alert

Question: Our surgeon performed an excisional biopsy for a male patient with a painful right breast mass. The pathology report returned with a diagnosis of gynecomastia. What are the correct diagnosis and procedure codes for this case?

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Answer: Assuming that the surgeon excised the mass, the correct procedure code is 19120 (Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion [except 19300], open, male or female, 1 or more lesions). The term "excisional biopsy" can be misleading, because the surgeon either excised the mass or incised a biopsy specimen from the mass. If the op note documents an incisional biopsy instead of an excision of the mass, you should report 19101 (Biopsy of breast; open, incisional).

The ICD-9 coding for this case is also problematic. Gynecomastia is usually a clinical diagnosis based on the clinician's observation of male breast enlargement, not a pathology diagnosis. Because ICD-9 requires that you report the most specific diagnosis known at the time, you would normally use the diagnosis from the path report, if you have it.

Unravel diagnosis source: Understand that ICD-9 doesn't provide diagnosis codes for "normal tissue." So, if the pathologist doesn't identify an abnormality, the path report should show the ordering diagnosis as the final diagnosis. If the surgeon performed the procedure because of a breast mass, the appropriate ordering diagnosis would be 611.72 (Lump or mass in breast). If the physician also noted that the patient had gynecomastia (611.1, Hypertrophy of breast), he might have used that as the ordering diagnosis, which the pathologist might have reflected on the path report.

Problem: Many payers consider gynecomastia treatment to be cosmetic, so you might not get paid for the procedure with a 611.1 diagnosis. Because you can't select the diagnosis code based on payment considerations, you'll need to clarify whether 611.72 is indeed the appropriate diagnosis before you report that code.